Attending call vs Residency call

[Undes1]

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Hey Yall,

TLDR: Is PP attending call easier, the same, or just different than call in residency? How can one negotiate to minimize Attending call/ burden?

My wife is currently interviewing for employed position with a physician owned PP group in a desirable area. The initial Zoom interview went really really well and she absolutely loves what she's hearing.... aside from the call schedule.

Apparently the practice is an even split between 7 docs (with her hired it would become 8). So q8w covering a Level 2 trauma at a local Non-Profit hospital.

She's currently getting her butt kicked on every call shift in her residency. The call has gotten so bad that her current program has had to start a night float as practically every call was so busy and the on call residents weren't sleeping for 36hrs straight. Im sure there's more nuance to this, but this is what I've retained from our conversations.

Many of her co-residents are suggesting only targeting job offers "with zero call" basically programs or practices that only take "practice call", or are able to divert any and all patients to the local academic center with residents or coverage.

The state we're in does this now. All patients are diverted to this academic center and that's the reason she's getting wrecked every call shift. The patients check into to local ERs pr PP's at noon, hours away, but don't actually make it to her until 3 am that night.

Im curious what yalls opinions are on this. Should she be worried about this q8w call? Is call as an attending better? Is it the same? is there a negotiation room to ease the call burden? We Love this practice and location but the call has here traumatized an nervous for taking on more once residency is over.

Or perhaps yall have some suggestions on what targeted questions she should ask to find out how easy or difficult call really is?

Thanks!

 

[eyeeye_captain]

How about we start with the good. Wife seems happy, physician owned, desirable area, democratic enough that call is split evenly, and it’s a big enough group that it’s q8.

The short answer with the call situation attending vs. resident is: it depends. So here comes the long answer.

As an attending you have more weight to throw around to say to send something to your clinic if it makes sense to. If it can’t go to clinic, you don’t have a consult resident to see an issue and you have to figure out when to go. If it’s surgical and within your scope, you’re on the hook. If it’s something that needs more follow up, you may be stuck rounding on it for a while.

Are there other hospitals in the area to dilute what’s coming in? What’s the culture - do all eyes go to midlevels who consult on all of them?

Level 2 non-profit reads to me as a busy safety net. You can ask the group, but I’m sure they’ll undersell how much work it is. My coresident took a gig years ago where the group covered a Level 1 that “we never see anything overnight” at. Hey, some money when they were broke, easy right? Called me crying after the first call week having done 3 open globes (still rounding on them) and been there 6 out of 7 nights. Best advice I’ve ever given was to tell them to find a sucker who needed the money even worse. Got a very nice bottle of wine 6 months later with a note thanking me for saving their sanity.

Practice only call will obviously be lighter, and in my mind very significantly so. As you alluded to, some markets can just ship things to the academic centers, but some (as per Matt here) are going to pretty much need some hospital work if you want to be there.

All this to get to your last questions:
- Having personally had call burnout, yes, I would worry at least a little.
- Attending call is always better with practice only, may be better than residency hospital call if said hospital is slow, may be worse than residency call if the hospital is busy as you don’t have any help.
- I highly doubt she can negotiate out of call if it’s equitable through the group. If it’s paid, maybe someone in that or another group would take it as above and let her have the practice only for that week, but a carve out like that for a new hire likely won’t fly unless they already do that.
- She should absolutely ask what the group’s culture is for handling calls, including surgical and floor work. Do they have somewhere to send patients if needed? Is it cool to have them see your partner if you’re at an office farther away? What’s the ED’s expectation for response/evaluation time? Again, you can ask the group about volume but they’ll probably sugarcoat it some as they’re looking to hire. Things come in waves so even if they tell you honestly that it’s slow, it can still blow up. If you know anybody else in the area, reach out. You can often find ED volumes and try to extrapolate to academic hospitals.

 

[Undes1]

Thanks for the response, extremely insightful.

Have you or anyone else heard of negotiating for minimal or zero regular clinic duties during the week of call?

example: from Friday 5pm to the week later Monday morning 8am, my wife is 100% dedicated to covering the call. If the Call is light then its an easy week, if the call is brutally busy then she works only the call patients and deals with their follow ups. The Clinic schedulers only load her absolute minimum patients starting at like noon or something.

Something along the lines of "During the week of call as described in contract, Dr. name maintains full scheduling control of regular clinic at named PP until conclusion of the call week."

I can imagine this would be unpopular for the partners total bottom line, but it could insulate her from the pain shes going through now in residency. Really she doesn't mind working all night and being busy, but being forced to also see all the regular clinic scheduled patients after no sleep is a difficult pill to swallow even if being paid well for it.

 

[Slide]

Thanks for the response, extremely insightful.

Have you or anyone else heard of negotiating for minimal or zero regular clinic duties during the week of call?

example: from Friday 5pm to the week later Monday morning 8am, my wife is 100% dedicated to covering the call. If the Call is light then its an easy week, if the call is brutally busy then she works only the call patients and deals with their follow ups. The Clinic schedulers only load her absolute minimum patients starting at like noon or something.

Something along the lines of "During the week of call as described in contract, Dr. name maintains full scheduling control of regular clinic at named PP until conclusion of the call week."

I can imagine this would be unpopular for the partners total bottom line, but it could insulate her from the pain shes going through now in residency. Really she doesn't mind working all night and being busy, but being forced to also see all the regular clinic scheduled patients after no sleep is a difficult pill to swallow even if being paid well for it.

I know people who get Monday following a call weekend off, but having zero regular clinic duties is going to be impossible unless she ran a solo clinic on her own.

I think what your wife needs to do is to talk to other people established in private practice before she makes any major decisions. She appears to be traumatized by residency and it's affecting her decision making process. Don't let her co-residents chime in too, it really sounds like everyone is doom spiraling wherever she's at. What she is imagining for call for is extremely atypical in private practice - most of the time call as an attending in many private practices is pretty light, and you can request the patients be sent to your office the next day in the morning unless there's a medical reason that's not possible - anything that urgent at a level 2 usually gets kicked up to a higher level of care anyway. She should also try to find a way to talk to ancillary staff that might be in the know (techs, schedulers, hospital staff) that have a more unbiased view of the call situation.

Most people I know in comprehensive private practice have an extremely nice lifestyle on the weekends. They only see patients at their clinic on call and rarely have to go in after dinner. Private practice call is also nothing like resident academic call - the good thing about private practice is that if it's not something she feels comfortable managing, she can refer/send it off.

One other thing she should look into is to see how call is reimbursed. The days of taking hospital call for free are over and she should demand a stipend. Call may not be great but getting paid for it at least takes some of the pain away - it'll also give you more freedom in your schedule.

 

[mjohnsonets]

Please do not have her try to negotiate out of the call if it's split completely evenly among the current docs, that will come across horribly and like she's not a team player.

I understand she's burned out now but she's a resident and the one getting dumped out. Call could still be a challenge depending on where you go but it's almost certainly going to be better than the current resident call. If the call is compensated at the local hospital, there is likely someone in the area that likes the extra money and can help cover her if she doesn't want it.

 

[dantt]

Please do not have her try to negotiate out of the call if it's split completely evenly among the current docs, that will come across horribly and like she's not a team player.

I understand she's burned out now but she's a resident and the one getting dumped out. Call could still be a challenge depending on where you go but it's almost certainly going to be better than the current resident call. If the call is compensated at the local hospital, there is likely someone in the area that likes the extra money and can help cover her if she doesn't want it.

100% . Would rub me the wrong way too.

 

[Undes1]

Please do not have her try to negotiate out of the call if it's split completely evenly among the current docs, that will come across horribly and like she's not a team player.

I understand she's burned out now but she's a resident and the one getting dumped out. Call could still be a challenge depending on where you go but it's almost certainly going to be better than the current resident call. If the call is compensated at the local hospital, there is likely someone in the area that likes the extra money and can help cover her if she doesn't want it.

100% . Would rub me the wrong way too.

Yeah she has no intention of trying to get out of call, only strategies to try and help her handle what could be a difficult call burden. And if none exist, then its probably not the right job for her.

She is 100% burned out by the call at her current program and is definitely trying to recover and grow to be able to handle call as an attending. But as I mentioned, every resident in her program is burned out too by the call and is specifically targeting jobs with zero or near zero call burden as a result. She's not he only one..

 

[eyeeye_captain]

If they had a system to pass the call off I suspect she would have been informed. A non-profit may not want to/be able to pay, which complicates things. There’s usually a reason a group will take on the headache - hospital employed, big local insurance that can only get surgery at that system, pay, or out of the goodness of their hearts.

Also agree that things are easier with being able to push things to clinic, as well as less volume than an academic dumping ground, but it can still be annoying if you get called on everything, have to clear every orbital fracture in the ED, etc.

I think she’s finishing PGY-2 now? That’s one of the lowest of the low points, so it will get better (disclaimer: I know some programs have tough PGY-3 call as well though). Certainly by the time she’s just backup she’ll see a difference and this will be in the rear view. I would have thought most of the really busy spots had gone to night float already; they’ve been talking about it at least since I was around.

Practice call can still get you. At least a couple times a year someone will call at 3 AM for some minor complaint when the clinic opens at 8.

 

[Undes1]

I think she’s finishing PGY-2 now?

Yep, and her program front loads PGY2 apparently, something she was aware of when she ranked them. But her rank position was based on call numbers that were substantially lower than they are now. Since Covid the call numbers have increased 7-10% YoY until now and projections are for it to continue to increase. The Night float model is really the only way the program can remain compliant with work hour restrictions given the crazy influx of patients in the past years.

Pgy3 and 4 will be easier call for sure, but in keeping with the original intent of starting this thread, we wanted to get the forums perspective on how residency call might differ, for better or worse, than attending call.

Again appreciate the insight from the group!

 

[Slide]

If there's no rush to sign the contract, let her just sit tight for several more months. PGY2 is always tough but it's necessary - sorry that your wife seems burned out but it's also very necessary for her development. Believe all of us when we say it'll get better and it's much easier as an attending. Even if she has to see the occasional patient on call as an attending, it'll be much easier with her training.

Not necessarily my place to say but I think your wife (and perhaps her co-residents) need to seek therapy after PGY-2 year is over and also let her PD know how bad it is.

 

[4ophtho]

Better:
Autonomy as an attending
You can decide when a patient needs to be seen and more control over schedule
Typically much less than what you’re used to in residency.

Worse:
No resident to screen BS consults
Life gets busier out of residency and call can be a bigger burden when you have a family (especially as a mother)
As you become busier in private practice call will interfere with your revenue generation

I took call for ten years at a busy level 1 trauma center and pay was great. It really helped me pay off loans, save for a mortgage payment, have extra cushion each month as I was building my practice. After 10 years I left call because it was becoming too much of a stress and money was less important.

If you are paid to take call you may able to take less if someone else in the group wants to take it.

If you’re not paid, you should be paid. Something you may address in the future.

Don’t start negotiations with requesting to take less call than the partners. You have to “pay your dues.”

It would be important to know if this level 2 center has the equipment for ocular trauma. If not, then a lot of that would be sent to a level 1 anyway.